Medical Errors Crisis: How Kaiser Permanente Leads Reform

Medical errors have caused a crisis in the national healthcare system. According to the Bureau of Primary Health Care, studies from Colorado, Utah, and New York estimate that 44,000 to 98,000 hospitalized people die in the United States annually due to medical errors (BPHC Task Force on Patient Safety, 2001, p. 5). In addition, as of March 31, 2010, the ten most frequently reported sentinel events within U.S. healthcare organizations are: wrong-site surgery; suicide; operative/post-operative complication; delay in treatment; medical error; patient fall; unintended retention of a foreign body; assault, rape, or homicide; perinatal death or loss of function; and patient death or injury in restraints (HealthLeaders Media, 2012). Clearly, many of these injuries and deaths are avoidable.

Furthermore, according to JCAHO's L.D. 5.2, patient safety concerns demand that "an ongoing, proactive program for identifying risks to patient safety and reducing medical/health care errors" be "defined and implemented" (Joint Commission on Accreditation of Healthcare Organizations, 2001). Consequently, the industry must design safer systems and demand accountability for the daily choices, actions, and omissions within those systems.

When questioning consumers about medical errors, researchers from the Kaiser Family Foundation/Agency for Healthcare Research and Quality first defined "medical error" with this statement: "Sometimes when people are ill and receive medical care, mistakes are made that result in serious harm, such as death, disability, or additional prolonged treatment. These are called medical errors. Some of these errors are preventable, while others may not be" (Henry J. Kaiser Family Foundation, 2004).

With that understanding, consumers traced medical errors to specific causes: approximately 74% believe that workload, stress, and/or fatigue among health care providers are important causes; 70% claim that the lack of time doctors spend with patients is another factor; 69% claim that some medical errors are caused by having too few nurses; and 68% claim that a lack of coordination and communication among health care providers is another important contributing cause (Henry J. Kaiser Family Foundation, 2004).

While there are a number of systemic barriers to providing safe care, Kaiser Permanente has specifically addressed two barriers within its own organization. First, the sheer size and scope of the organization can form a significant systemic barrier: coordinating efforts in a system serving over 9 million members across 8 regions with 180,600 employees (Kaiser Permanente, 2012) is a daunting task. Second, Kaiser Permanente has pointed to a legal and social system that is too focused on punishing providers through medical malpractice suits, resulting in high malpractice insurance costs and a culture of fear, rather than one that justly compensates victims of medical errors while promoting education and improvement (Henry J. Kaiser Family Foundation, n.d.). Despite these barriers, The Leapfrog Group has given relatively high safety ratings to Kaiser Permanente hospitals (Kaiser Permanente, 2012).

Kaiser Permanente has responded to the medical error crisis by developing a culture dedicated to heightening the quality of patient care while reducing costs. In order to attain its goals across a very large system, Kaiser has developed fundamental principles that have been lauded by the Commonwealth Fund. By studying Kaiser Permanente's operations, the Commonwealth Fund identified six attributes it highly recommends to other health care providers:

Information Continuity ensures that every patient's medically relevant data is made available to all providers "at the point of care" and to the patient through electronic records. Care Coordination and Transitions manages coordinated patient care among multiple providers and across multiple care settings. System Accountability provides clear-cut accountability for a patient's total care. Peer Review and Teamwork for High-Value Care holds health care provider teams — both within a single institution and across Kaiser's multiple institutions — accountable to one another, encouraging review of each other's work and continual collaboration to improve quality and value. Continuous Innovation ensures that providers throughout the system are continually learning and innovating to improve patient care. Finally, Easy Access to Appropriate Care means that appropriate care is available throughout the system at all hours, and that providers within each care setting are "culturally competent" and responsive to the individual patient's needs (McCarthy, Mueller, & Wrenn, June 2009, p. 2).

While Kaiser has protocols dealing with specific medical errors, its policy for disclosing errors to patients in order to promote patient safety is particularly laudatory. According to the Commonwealth Fund, Kaiser Permanente has developed a "multipronged" approach for disclosure of medical errors to patients, which greatly promotes patient safety. The principles forming the basis for Kaiser Permanente's philosophy are: high regard for patient care; ready communication about unanticipated bad outcomes; communicating to the appropriate parties; checking medical records; following up on treatment and providing closure; and supporting the team devoted to patient care (McCarthy, Mueller, & Wrenn, June 2009, p. 3).

Accordingly, Kaiser has employed proactive training for physicians, "situation management teams," and health care ombudsmen to have open and meaningful discussions with patients and their families about adverse events and medical errors, to support health care providers as needed, and to facilitate valuable communication between the health care institution and the patient or family (McCarthy, Mueller, & Wrenn, June 2009, p. 3). This open, communicative, and positive culture has resulted in favorable feedback and greater awareness of medical errors and adverse outcomes among providers, patients, and their families.